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Fig. 15.1 Ultrasound (US)
image of Stensen’s duct
calculi (arrow) and dilated
proximal duct (asterisk)
O. Edkins and J. J. Fagan
Fig. 15.2 US image of Wharton’s duct calculus (arrow) and dilated
proximal duct (asterisk)
15.1.3 Informed Consent
As with any surgical procedure, informed consent is necessary to ensure that the patient has a suitable understanding and expectation of the outcomes and risks of
surgery. The potential consequences or complications
that need to be discussed vary according to the procedure
planned:
• Sialendoscopy:
– The benets of the minimally invasive nature of the
procedure, weighed against the limitations of the procedure to remove larger or unsuitably located calculi
– The possibility that a repeat procedure will be
necessary
– Infection, inammation, and oedema
Fig. 15.3 US Image of Wharton’s duct dilatation (asterisk) from a dis-
tal duct calculus
– Perforation of the duct, which may require stenting or
a further open procedure
– Delayed stenosis of the duct
– Instrumentation failure or entrapment within the ductal
system, which may necessitate open surgical removal
• Transoral sialolithotomy:
– Bleeding, infection, inammation, and oedema
– Injury to the lingual nerve, in the case of the subman-
dibular duct
– Delayed stenosis of the duct, especially relevant with
the parotid duct
• Transcutaneous, transfacial approach to a parotid stone:
– Surgical scarring
– Bleeding, infection, inammation, and oedema
– Injury to branches of the facial nerve
– Paraesthesia in the greater auricular nerve distribution
– Sialocoele or salivary stula
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151
ric or adolescent patient) to tolerate a procedure performed
under local anaesthesia.
With sialendoscopy, general anaesthesia is preferred for
calculi that may require prolonged surgical time or signicant instrumentation to remove a calculus. Transoral open
sialolithotomy for Wharton’s duct calculi may readily be
performed with local anaesthesia, but a stone located posteriorly may require general anaesthesia for successful
removal.
Nasotracheal intubation is preferred notto impede access,
especially when working on Wharton’s duct and the oor of
the mouth. This is also true for Stensen’s duct, although an
orotracheal tube placed to the contralateral side may sufce.
15.1.5 Equipment
Availability of appropriate equipment is an important consideration when planning removal of calculi by means of
sialendoscopy. Access to appropriate-size sialendoscopes,
dilators, stone extractors and graspers, and stone fragmentation equipment is essential.
Fig. 15.4 CT image of Stenson’s duct calculi (arrow)
Fig. 15.5 CT image of Wharton’s duct calculus (arrow)
15.1.4 Anaesthesia
The choice of anaesthesia depends on the surgical approach,
the expertise of the surgeon, comorbidities affectinggeneral
anaesthesia, and the ability of a patient (especially a paediat-
15.2 Indications
Surgical removal of salivary stones has two indications:
• Recurrent obstruction and swelling of the gland with
meals that does not respond to conservative measures
• Obstructive sialadenitis
Currently, the choice of surgical approach is gland-sparing
surgery, where the surgery includes diagnostic and interventional sialendoscopy, open transoral sialolithotomy, or a
combination of the two; sialadenectomy is reserved for a signicantly smaller portion of cases than was previously indicated [2].
Surgery is best performed once acute infection has settled
with appropriate medical therapy. This is especially true with
sialendoscopy, as the presence of acute infection signicantly raises the risk of duct perforation and the spread of
infection into the surrounding soft tissues.
Figure 15.6 outlines a stepwise approach to the removal
of intra-canalicular stones. Somelarger stones may be amenable to fragmentation by extracorporeal shockwave lithotripsy (ESWL) or intracorporeal lithotripsy (using laser or
stone-fragmentation devices), thus rendering them removable by sialendoscopy. Staging of the procedures may be
required to achieve successful removal of all fragments of
the calculus.
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Obstructive symptoms of
major salivary gland
High definition
ultrasound (US)
Dilated Duct with Intra-
ductal Calculus
O. Edkins and J. J. Fagan
Inconclusive US:
Consider CT Scan to
assess stone size & position
Small calculus
submandibular: ≤ 4 mm
parotid: ≤ 3 mm
Endoscopic Removal
Intermediate calculus
submandibular: 4.1 – 6 mm
parotid: 3.1 – 6 mm
Intra-ductal calculus
Visible at endoscopy
Fragmentation possible:
YES
Calculus palpable Calculus not palpable
Combined open approach Gland removal
Micro-bur or intra
corporeal lithotripsy
NO
Consider extra-corporeal
Diagnostic sialendoscopyDiagnostic sialendoscopy
lithotripsy if
available
Large calculus > 6mm
Intra-glandular calculus
OR not visible at endoscopy
Fig. 15.6 Management algorithm for intra-canalicular salivary calculi
15.3 Surgical Technique withTips
15.3.1 Sialendoscopy
• Equipment and theatre setup:
– Care should be taken when handling the delicate
sialendoscopes. (Adequate training should be provided
to all staff.)
– The surgeon is generally situated on the right-hand
side of the patient, with the assistant or nurse on the
opposite side.
– A mobile cart with operating light source, video cam-
era, and monitor is placed at the head of the patient, in
full view of the surgeon.
– The sialendoscope (Fig.15.7) is connected to the video
camera, taking care that the image is correctly oriented
to ensure that each direction of movement of the scope
matches that of the image generated on the monitor.
This will avoid disorientation during the procedure.
• Dilation and access to the submandibular duct:
– Surgical loupe magnication is very helpful.
– Expose the oral cavity with an appropriate-sized bite
block for an unobstructed view of the oor of the
mouth.
– Stabilise the mucosa with a ne-toothed forceps placed
posteriorly and superiorly relative to the papilla.
– Alternatively, retract the tongue posteriorly towards
the contralateral side with the index nger, straightening out the papilla, the duct, and angle of approach.
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– Use conical dilators and probes (Fig.15.8) of increas-
ing diameters to cannulate and dilate the duct
(Fig.15.9) prior to introducing the scope. Alternating
the conical dilator in between two serial sizes of probes
may facilitate access.
– A very narrow papilla may require insertion of a guide-
wire and the Seldinger technique and dilators to dilate
it.
– Failure to cannulate the duct is not an infrequent expe-
rience, especially when the surgeon is learning the procedure. Surgical exploration of the oor of the mouth
to identify the anterior duct may be necessary. A small
longitudinal incision, just large enough for the sialendoscope to be passed, can be made into the duct to
facilitate the rest of the procedure.
– Following dilation of the duct, the tip of the scope is
passed into the duct.
Fig. 15.7 Sialendoscope (1.3-mm Marchal Scope, Karl Storz
Endoscopy)
• Dilation and access to the parotid duct:
– Surgical loupe magnication is very helpful.
– Expose the oral cavity with an appropriate-sized bite
block for an unobstructed view of the buccal mucosa.
– Stabilise the buccal mucosa by gently retracting the
cheek anterolaterally at the corner of the mouth.
(Negotiating the sialendoscope past the natural bend in
the duct around the masseter muscle is also facilitated
by this maneuver.)
– Use conical dilators and probes (see Fig. 15.8) of
increasing diameters to cannulate and dilate the duct
prior to introducing the scope. Alternating the conical
dilator in between two serial sizes of probes may facilitate access.
– A narrow papilla may require insertion of a guide-wire
to determine the presence of stenosis prior to dilation.
– Following dilation of the duct, the tip of the scope is
passed into the duct.
• Endoscopic assessment of the ductal system:
– A suitably sized sialendoscope is used for adult or pae-
diatric patients, as well as for the anticipated instrumentation required during the procedure.
– Continuous irrigation is essential, generally with nor-
mal saline. A diluted corticosteroid solution may be
used in cases of chronic sialadenitis. The total volume
of irrigation should be kept to less than 20 mL, but
more may be needed for exceptionally long and challenging cases.
– Lidocaine 1% may be added to the solution, especially
when surgery isperformed under local anaesthesia.
– The sialendoscope is advanced slowly, maintaining
and following the lumen of the duct in the middle of
the view.
– An obstructed view may result from a stricture or the
tip of the scope being placed up against the wall of the
Fig. 15.8 Dilators for
sialendoscopy (Karl Storz
Endoscopy)
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Fig. 15.9 Cannulation of Wharton’s duct
O. Edkins and J. J. Fagan
Fig. 15.10 Endoscopic view of proximal Wharton’s duct calculus at
sialendoscopy. Although the initial appearance is of an impacted stone,
this may be found to be oating and mobile when the scope is passed
nearer to the stone
duct. When this occurs, the scope is slowlywithdrawn
to bring the lumen into view again.
– Endoscopic assessment of the obstructing calculus is
then possible, noting its position, its size compared to
the duct, and whether it is oating or impacted
(Fig.15.10).
• Endoscopic removal of the calculus:
– Removing the calculus is best achieved with a basket
(Fig. 15.11), which is passed through the working
channel of the sialendoscope.
– The closed basket is advanced past the calculus and
opened proximal to the calculus by the assistant.
– The surgeon then withdraws the basket while maneu-
vering the wires around the calculus.
– The basket is closed to ensnare the calculus, and
withdrawn.
– Certain types of baskets are opened in front of the cal-
culusto encircle the calculus from anteriorly.
– Calculi that are large and/or impacted require frag-
mentation by means of laser or ESWL prior to removal
witha basket or with grasping forceps.
– Calculi that are inadvertently impacted within the duct
after engagement of the basket may require conversion
to open surgical removal. This possibility should
always be discussed preoperatively when obtaining
consent for the procedure. Should the situation arise in
which the basket cannot be released or disengaged
from an impacted calculus, one should not forcibly
withdraw the basket, as doing so may avulse the duct.
Fig. 15.11 Endoscopic view of retrieval of calculus with a basket
– A small papillotomy may be required to deliver the
calculus at the orifice of the submandibular duct
without much consequence (Fig. 15.12). This
should generally be avoided with the parotid duct,
but if unavoidable, the duct should be stented
thereafter.
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Fig. 15.12 Wharton’s duct papillotomy to remove the calculus
ensnared with the basket (arrow)
15.3.2 Transoral Removal ofaSubmandibular
Duct Stone
• Transoral removal can be performed under local or gen-
eral anaesthesia.
• Administer local anaesthesia, with a vasoconstrictor, in
the mucosa of the oor of the mouth at the site of the
planned surgical incision, generally directly over the palpable calculus.
• Placement of a suture around the duct, posterior to the
stone, prevents posterior displacement of the calculus.
• Incise through the mucosa directly onto the stone with a
blade or electrocautery.
• The calculus can be removed under direct vision
(Fig.15.13).
• Marsupialisation of the opening in the duct may be con-
sidered, suturing the cut edges of the duct to the oral
mucosa with absorbable interrupted sutures, such as 4/0
vicryl.
• Irrigation of the ductal system with normal saline facili-
tates evacuation of purulent saliva retained behind the
obstruction.
• Calculi located more posteriorly within the proximal duct
may also be removed through a sialolithotomy procedure.
This carries an increased risk of injury to the lingual
nerve, especially in the posterior third of the duct, as well
as the possibility of bleeding from the ranine veins or
more severe bleeding from the lingual vessels [1].
Fig. 15.13 Transoral removal of submandibular duct calculus
• Access and success may be improved by using a longer
incision starting more anteriorly, so as to identify the relevant structures within the oor of the mouth.
• Opening the duct more anteriorly to the calculus and performing a duct-slitting procedure, remaining within the
lumen of the duct whilst dissecting posteriorly to locate
the calculus, is useful in these cases [2]. Care should be
taken to identify the location of, and preserve, the lingual
nerve.
15.3.3 Transoral Removal ofanAnterior Third
Parotid Duct Stone
• Transoral removal can be performed under local or general anaesthesia.
• Administer local anaesthesia, with a vasoconstrictor, in
the mucosa surrounding the papilla of Stensen’s duct.
• Cannulate the duct with a dilator and probe, advancing
the probe along the duct until the stone is felt.
• Secure the papilla and probe with forceps or a
haemostat.
• A circumferential elliptical incision is made around the
papilla.
• Dissection around and along the duct is performed to the
point of the calculus.
• An incision is made in the duct wall over the calculus
(Fig.15.14).
• The stone is then delivered through the sialolithotomy
incision.
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Fig. 15.14 Transoral removal of anterior-third parotid duct calculus
• Following removal, massaging the gland will facilitate
clearanceof any purulent saliva.
• The duct wall may then either be sutured with 6/0 prolene
over a stent, suturing the mucosa around the papilla into
place with 4/0 vicryl, or the sialolithotomy may be sutured
to the buccal mucosa with interrupted 4/0 vicryl to maintain patency of the duct.
• Insertion of a stent is often required to prevent stenosis of
the neosteum of the duct, which is more commonly
encountered with Stensen’s duct than with Wharton’s
duct. A wide variety of stents may be used, from commercially available stents to 5F paediatric feeding tubes,
umbilical catheters, Silastic tubes, or polyethylene intravenous catheters. The appropriate diameter for the duct
should be selected.
15.3.4 Transcutaneous Removal ofaMiddle
andPosterior Third Parotid Duct Stone
• This procedure is performed under general anaesthesia.
• Care should be taken when considering this approach for
a posterior-third calculus, which may be deeper within the
gland where the duct wall is thinner and less amenable to
adequate repair after removal of the calculus [4].
• The procedure is commenced with sialendoscopy and
location of the calculus. The sialendoscope may be left in
situ during the transcutaneous surgical approach, with the
light being a useful guide to the location of the calculus.
O. Edkins and J. J. Fagan
Fig. 15.15 Transcutaneous approach to a parotid duct calculus, visible
within the duct
• Alternatively, the position of the calculus may be marked
on the skin overlying the light of the endoscope prior to
removal of the scope, with careful translation of this
marking onto the supercial musculoaponeurotic system
(SMAS) layer after elevating the skin ap.
• Facial nerve monitoring is recommended to avoid injury
to the buccal branch, which courses along Stensen’s duct.
• Inltration with local anaesthesia and a vasoconstrictor is
useful.
• The approach is via a standard parotidectomy or face-lift
skin incision, with elevation of the skin ap anteriorly to
beyond the location of the calculus.
• An anteriorly based U-shaped ap may be made in the
SMAS layer and elevated over the location of the calculus. Care should be taken to avoid injury to the buccal
branch of the facial nerve [4, 5].
• Alternatively, if the calculus is palpable within the duct,
dissection onto the calculus may be performed through
the SMAS layer.
• The duct is identied and an incision made longitudinally
over the calculus, which is then removed (Fig.15.15).
• The duct is sutured with 6/0 prolene after placement of a
stent (Fig.15.16), which should extend from the operated
region into the oral cavity and should be secured to the
buccal mucosa near the papilla of the duct.
• The SMAS layer is then sutured with absorbable suture
material, followed by closure of the skin incision.
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Fig. 15.16 Transcutaneous approach with stenting of the parotid duct
after removal of the calculus
15.4 Postoperative Care
Sialendoscopy and intraoral sialolithotomy may be performed as day-case surgery in suitable patients. If signicant
157
swelling occurs within the oor of the mouth or the cervical
region, it is advisable for the patient to be monitored in hospital overnight, with special attention to airway observations.
An initial follow-up should be undertaken at 10–14 days,
with a further follow-up at about 2–3months. Sutures within
the oral cavity may be removed at the rst postoperative
visit. Any stent that has been placed may be removed after
2weeks. Attention should be given thereafter to any stenosis
of the papilla of the ducts or of a neosteum that has been
surgically created.
References
1. Witt R, Edkins O.Sialolithiasis: traditional & sialendoscopic techniques. Open access atlas of otolaryngology, head & neck operative surgery. Cape Town: Faculty of Health Sciences, University of
Cape Town. 2016. http://www.entdev.uct.ac.za. Accessed December
2017.
2. Koch M, Zenk J, Iro H.Algorithms for treatment of salivary gland
obstructions. Otolaryngol Clin North Am. 2009;42:1173–92.
3. Marchal F, editor. Chapters 10–14. Sialendoscopy, The hands-on
book. Geneva: ESTC; 2015. isbn:978-2-8399-1625-7.
4. Marchal F. A combined endoscopic and external approach for
extraction of large stones with preservation of parotid and submandibular glands. Laryngoscope. 2007;117:373–7.
5. Marchal F, editor. Chapter 84. Sialendoscopy, the hands-on book.
Geneva: ESTC; 2015. isbn:978-2-8399-1625-7.
Partial Parotidectomy Including Deep
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Lobe andDumb Bell Tumours
NickRoland, MariaCasasayas, andMiquelQuer
16.1 Introduction
The traditional procedures in the treatment of parotid gland
tumours have been supercial and total parotidectomy.
However, during the twentieth century, it became apparent
that less parotid tissue could be resected reducing the high
morbidity and complication rates associated with comprehensive surgery whilst maintaining similar outcomes in tumour
control. Partial parotidectomy has now emerged as a standard
of care in the treatment of parotid gland pathology. The denition of partial parotidectomy is not well established, but the
basis is to remove less parotid tissue than in a comprehensive
parotidectomy. In 2016, the European Salivary Gland Society
proposed the term “partial parotidectomy” as the procedure
based on the dissection of the facial trunk and the removal of,
at least, one of the parotid levels according to the ESGS proposal (Fig.16.1) [2]. This denition is a little cumbersome as
it excludes one of the other partial parotid resection techniques that has emerged in extracapsular dissection. The main
differences with extracapsular dissection are that this method
does neither include the intentional dissection of the facial
nerve nor a cuff of normal parotid tissue.
Partial parotidectomy can be performed either be supercial or deep to the facial nerve. Some tumours affecting deep
levels extend into the parapharyngeal space, so-called Dumb
Bell Tumours. Therefore, deep lobe partial parotidectomy
can encompass the dissection of this parapharyngeal area.
N. Roland (*)
Aintree University Hospital NHS Trust, Liverpool, UK
e-mail: Nick.Roland@LiverpoolFT.NHS.UK
M. Casasayas
Otorhinolaryngology Department, Hospital de la Santa Creu i Sant
Pau, Universitat Autònoma de Barcelona, Barcelona, Spain
e-mail: mcasasayas@santpau.cat
M. Quer
Department of Otorhinolaryngology–Head and Neck Surgery,
Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de
Barcelona, Barcelona, Spain
e-mail: mquer@santpau.cat
16
I
Fig. 16.1 ESGS division in ve levels (modied from Quer etal. [1]).
The division in ve levels: I (lateral superior), II (lateral inferior), III
(deep inferior), IV (deep superior), V (accessory). The superior level is
the area corresponding to the branch of the temporofacial nerve and the
inferior level the area of the cervicofacial branch
Partial parotidectomy is indicated for excision of benign
tumours, but other indications include excision of low-grade
malignant tumours and inammatory disease.
16.2 Preoperative Checklist,
Considerations, andAnaesthesia
16.2.1 Clinical Assessment
The usual presentation of benign tumours is a slow-growing
painless mass. Rapid growth, pain, tethering of the skin,
ulceration of the skin, cervical lymphadenopathy, and facial
IV
V
II
III
© Springer Nature Switzerland AG 2024
R. Simo et al. (eds.), Atlas of Head and Neck Surgery, Springer Surgery Atlas Series,
https://doi.org/10.1007/978-3-031-36593-5_16
159
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N. Roland et al.
nerve paralysis are all suggestive of malignancy. Tumours
low in the tail of the parotid gland can easily be confused
with an upper cervical lymph node. Bilateral parotid tumours
are most common in Warthin’s tumours and HIV related
lymphoepithelial cysts.
All patients with a mass in a salivary gland should have an
inspection and palpation of the mass itself. Oral examination
should be with inspection of the relevant salivary gland duct.
The parotid (Stenson’s) duct is situated opposite to the upper
second molar. Inspection of the oropharynx for parapharyngeal extension should be performed, which will usually manifest as medialization of the tonsil. Facial nerve assessment is
mandatory, as is neck node palpation. The head and neck
skin should be checked for cancers.
16.2.2 Investigations
Ultrasound scan (USS) provides invaluable information
about the site, size, and nature of salivary gland tumours and
the presence of cervical lymphadenopathy. The position of a
tumour in the supercial or deep aspect of the parotid gland
is established by identication of its relation to the retromandibular vein. It is usually combined with ne-needle aspiration biopsy (FNA) (USSgFNAB) which improves the
adequacy rate. In experienced hands, this can distinguish
malignant from benign disease in 80–90% of cases.
FNA is established as the primary diagnostic tool for salivary gland lesions. It is a relatively painless procedure, has
few complications (seeding of the tumour does not appear to
occur), and may prevent an ill-advised and often ill-fated
incisional or excisional biopsy of a parotid mass. There are
sometimes issues regarding aspiration technique, adequacy
of specimen, cytological expertise, and limitations of the
interpretation. If the result of FNA is at variance with other
ndings, then clinical judgement should prevail.
Cross-sectional imaging is not essential in straightforward benign tumours, but MRI scanning of a parotid tumour
is useful in the assessment and delineation of anatomical
structures, in particular, to verify extension to the deep lobe
and relationship to the facial nerve [3].
16.2.3 Consent
Prior to supercial or total conservative parotidectomy, the
patient should be warned about the following serious or frequent complications.
1. Facial weakness: The risk of temporary or permanent facial
weakness must be carefully explained as it has a signicant
impact on quality of life. The risk of facial nerve damage is
related to the type and extent of the disease, the type of
resection, and the experience of the surgeon. The risk of
permanent facial palsy is in the region of 1–2%.
2. Haematoma.
3. Salivary stula or collection (sialocoele).
4. Sensory Loss: Some loss in the distribution of the greater
auricular nerve, over the angle of the mandible and inferior two- thirds of the pinna, is unavoidable. All attempts
to preserve the posterior branch of the greater auricular
nerve should be made as this will reduce the initial loss of
sensation. In any case, the area of sensory loss generally
decreases in the rst 12months post-operatively.
5. Cosmetic defects: The skin incision rarely causes huge
concern, because the most visible components are in skin
crease lines or a face lift incision can be used. With larger
tumours, loss of bulk behind the ramus of the mandible
may be visible. This can be moderated with fat transfer.
6. Frey’s syndrome: Gustatory sweating or ushing (Frey’s
syndrome).
7. Neuroma of the greater auricular nerve.
8. Recurrent tumour. The risk of recurrent tumour is
increased if there has been spillage of the tumour or
incomplete excision.
9. Further treatment: Patients should be warned that they
may require radiotherapy, both in event of their being a
complication or in the scenario that an unexpected malignant histological result is obtained.
General anaesthesia is required to perform partial parotidectomy. The anaesthetist must avoid paralytic agents so that
the facial nerve can be monitored. No prophylactic antibiotics are required before the surgery.
16.3 Indications
1. Benign tumours of the parotid gland. The most frequent
indication is limited tumours of the supercial lobe, especially of the tail. These tumours can be approached by
exposing the nerve trunk and mobilising the inferior
aspect of the gland containing the tumour by a so-called
hemi-supercial parotidectomy. An alternative is to
excise the tumour by extracapsular dissection.
2. When the tumour is in the deep lobe or is a Dumb Bell
tumour, a deep partial parotidectomy can be done preserving the supercial lobe. The main advantage of this
technique is to preserve more parotid tissue and expose
less the facial nerve, so as to reduce complications and
sequelae. Its main indication is benign limited size
tumours located at one of the borders of the gland, which
allows a resection very similar to that we would obtain
with a more conventional surgery but preserving tissue
sufciently distant from the tumour.
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